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-y, \ t e * APPLICATION FOR PERMIT s - SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA � Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worK h�rheirnecn s applic afi made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. �t/ City Gr Lof Size PM Job Address ,�) J Owner's Name �4 � �A ss �� f G ll'�L 4 O� Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �- El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications El Domestic/Private ❑ Gravel Pack ❑ Type of Casing Tracy Type of Grout (� M Public P Other F I Delta Depth of Grout Seal I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system in permitted if public sewer is availabInstallation will serve: Residence_ CPrRIRED - t ( Number of living units: Number o Character of soil to a depth of 3 feet: , "� ' Water table depth SEPTIC TANK ❑ Type/Mfg r�avctgi No. Compartments Pe ' I,t,[T34,7 Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearglprk I'pq co °!°'IW1 o nin ec Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requi„ inspections. Complete drawing on reverse side. e1 Signed Date: ILL OR D ARTMENT USE ONLY Q 2"y Date v J Area Application Accepted by 1_ I�Qp� i L Date Final inspection by T77R f Date Pit or Grout Inspection b �I Additional Comments: —�v` ^'vL` ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823WN ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K H RECE VIED BY DATE PERMIT'NO. q + EH 13-24(REV.1/X 5)7 ry o EH 14-26